Airway Trauma

Lindsey A. Nelson, MD
University of Cincinnati College of Medicine
Cincinnati, Ohio

Initial treatment of airway injuries caused by penetrating trauma

was initially discussed as early as 1792 by Hugh Munro a surgeon from
Scotland.1 Fortunately, traumatic laryngeotracheal injury is relatively
uncommon and may occur after blunt or penetrating trauma but should
always be considered life-threatening. The exact number may be
underreported, as severe injuries are usually immediately fatal. A high
index of suspicion must always be maintained to avoid either iatrogenic
injury during endotracheal intubation and missed diagnosis. These
injuries complicate the primary goal in any patient after an injury:
ensure a patent airway. This chapter reviews several factors involved
to facilitate evaluation and diagnosis of these injuries. Management of
these injuries will focus primarily on airway management while
discussion on surgical treatment will be limited.

’ Anatomy

A review of the laryngeotracheal anatomy and the relationship to

adjacent structures is critical for expeditious diagnosis and management
of these injuries. In general, the airway is fairly mobile with a fixed
attachment only at its superior margin. This flexibility in movement
allows the laryngeotracheal complex to absorb impact and likely plays a
major role in the low incidence of airway injury especially in the blunt
trauma patient.2 Suspended from the hyoid bone the structure passes
through the neck and into the thorax connecting to the lungs via the
bronchi. Despite the lack of continuous fixed attachments, the larynx
and trachea are somewhat secured by surrounding structures and
tissues. The cervical portion of the trachea extends throughout zone 1,

REPRINTS: LINDSEY A. NELSON, MD, DEPARTMENT OF ANESTHESIOLOGY, UNIVERSITY OF CINCINNATI COLLEGE

OF MEDICINE, PO BOX 670764, 234 GOODMAN STREET, CINCINNATI, OH 45267-0764, E-MAIL: NELSONLY@
UCMAIL.UC.EDU

99
100 ’ Nelson

the region from the cephalad border of the clavicle to the cricoid
cartilage, and is covered by the thyroid gland, strap muscles, and
cervical fascia anteriorly.3 The recurrent laryngeal nerves lie in each
tracheoesophageal groove, whereas the carotid sheath lies lateral to the
cervical trachea and contains the common carotid arteries, internal
jugular veins, and vagus nerves (Fig. 1). Posteriorly, the trachea is
protected by the cervical spine and the membranous portion lies in close
approximation to the esophagus.4
The larynx is a tube-shaped structure comprised of a complex
system of muscle, cartilage, and connective tissue. The framework of the
larynx is composed of 3 unpaired and 3 paired cartilages. The thyroid
cartilage is the largest of the unpaired cartilages, and resembles a shield
in its shape. The most anterior portion of this cartilage, commonly
referred to as the ‘‘Adam’s apple,’’ can be very prominent in some
men increasing its susceptibility to injury. The second unpaired
cartilage is the cricoid cartilage. Its shape, often described as a ‘‘signet
ring,’’ defines the lower limit of the larynx. The third unpaired cartilage
is the epiglottis, which is shaped like a leaf which functions to protect
the entrance of food and liquids into the laryngeal inlet during
swallowing. The 3 paired cartilages include the arytenoid, cuneiform,
and corniculate cartilages. The arytenoids are shaped like pyramids,

Figure 1. The anatomy of the larynx and surrounding structures. Note the tracheal cartilage of the
larynx that can be felt as the Adam’s apple in the front of the neck. Below the larynx lies the trachea.
The larynx and trachea are partially covered by the thyroid gland. Copyright T. Graves.
 Anesthetic Management of Airway Trauma ’ 101

and because they are a point of attachment for the vocal cords, allow
the opening and closing movement of the vocal cords necessary
for respiration and voice. The cuneiform and corniculate cartilages
are very small, and have no clear-cut function. They are all connected
together by fibrous tissue and smooth muscle.4 The endolarynx is
lined with mucosa which is supported by a sheet of elastic tissue.
The conus elasticus occurs when this tissue thickens in the anterior
and posterolateral margins, binding the thyroid, cricoid, and arytenoid
cartilages together. At the connection of the larynx and the trachea, the
cricotracheal ligament exists. Although this membrane is fairly elastic, it
is also thin increasing its susceptibility to separation.
The larynx is innervated by branches of the vagus nerve (cranial
nerve X) on each side. Sensory innervation to the glottis and supraglottis
is by the external branch of the superior laryngeal nerve. The inferior
branch of the superior laryngeal nerve innervates the cricothyroideus.
Motor innervation to all the other muscles of the larynx and sensory
innervation to the subglottis is by the recurrent laryngeal nerve. It
penetrates between the cricoid and thyroid cartilages and is frequently
damaged in patients with laryngeal injury.5,6
As the trachea passes into the mediastinum through the thoracic
inlet, it lies posterior to the innominate vein and artery. This close
orientation to the innominate artery is the cause for the highly lethal
tracheal innominate artery fistula in patients with a tracheostomy in
place.7 On average, the innominate artery passes in front of the trachea
at the level of the ninth tracheal ring; however, considerable variability
exists and can range from the sixth to the 13th ring. Further caudal, it
passes posterior to the aortic arch, and posterior and to the left of the
superior vena cava. The carina is located at the level of the sternal angle
anteriorly and the T4–5 intervertebral disc posteriorly (Fig. 2).
Additional structures include the pericardium anteriorly, the ascending
aorta, and the proximal aortic arch.
The left mainstem bronchus measures 3 to 4 cm in length and passes
posterior to the aortic arch and left atrium while just anterior to the
esophagus and proximal descending thoracic aorta, because the early
take-off of the right upper lobe the right mainstem bronchus is shorter
than the left, approximately 1.5 to 2 cm. It passes posterior to the
azygocaval junction as it moves laterally and caudally. Both mainstem
bronchi lie posterior to their respective pulmonary artery which help
anchor the bronchi within the thoracic cavity.4,8
Generally, half the trachea resides within the neck; however, this can
change significantly on the basis of the position of the neck and the
patient’s body habitus. Cervical kyphosis and neck flexion can markedly
reduce the length of trachea above the sternal notch. In contrast, neck
extension and patients with long necks may increase the amount of
trachea above the sternal notch. Therefore, position of the neck at the
102 ’ Nelson

Figure 2. Anterior thoracic anatomy of the trachea. The great veins and aortic arch pass anterior
to the trachea. From Cervicothoracic Trauma. New York: Thieme Inc; 1986:119.

time of injury and the patient’s body habitus may significantly influence
the level of laryngeotracheal injury.

’ Incidence

Laryngeotracheal injury is rare. Exact incidence is difficult to

determine as the more serious injuries can be immediately fatal and may
only be detected on autopsy.9 Many factors including the mechanism of
injury, injury site, time until diagnosis, additional injuries, interventions
undertaken, and age of the patient contribute not only to the low
survival but to the inability to accurately detect injuries to the larynx
and trachea.10–13 Overall incidence approximates 0.5%; however,
this can range significantly based on the aforementioned factors.14,15
Verschueren and colleagues2 reported an incidence of 0.002% in
severely injured patients presenting with associated head, face, and neck
injuries. Whereas, Bertelsen et al9 reported an incidence of laryngeo-
tracheal injury as high as 2.8% in an autopsy series of all fatal trauma
victims presenting at their trauma center.
 Anesthetic Management of Airway Trauma ’ 103

In regards to injury severity, Ecker et al10 reported in a retrospective

study of 104 tracheal and bronchial injuries that approximately 80% of
deaths occurred before arrival to the hospital. This corroborates other
studies that show between 70% and 80% of victims who sustain airway
injuries die before receiving definitive medical attention.9,14 Albeit most
of these victims represented multitrauma injuries and not isolated
laryngeotracheal damage, assignment of exact cause of death likely
includes the plurality of injuries but reinforces the high mortality in
trauma patients with these injuries. Unfortunately, death may also occur
iatrogenically during endotracheal intubation in a patient with an
undiagnosed laryngeotracheal injury. In this case no injury may be seen
on direct laryngoscopy, however as the endotracheal tube is passed
further into the trachea it may inadvertently advance into a false passage
causing complete airway obstruction.5,16
Owing to the close proximity of the anatomic structures, penetrating
neck injuries have a higher incidence of laryngeotracheal injury in
comparison with penetrating chest trauma. Whereas 3% to 6% of
penetrating neck injuries have associated cervical tracheal injury less
than 1% of patients with chest injury from the same mechanism have
airway injury.17 Kummer et al18 recently reported their 16-year
experience treating traumatic airway injuries and found an incidence
of 0.4% and 4.5% for blunt and penetrating trauma, respectively. Of all
23 patients with laryngeotracheal injuries over a 6-year period, Francis
et al19 reported that 19 were sustained after penetrating (gun shot
wound, 12; stab wound, 7) in comparison with only 4 patients who were
identified with laryngeotracheal injury after blunt trauma.
Most agree that the overall incidence of tracheobronchial injury
after blunt trauma including blunt trauma to the neck is 0.5% to 2%
with most of the disruptions occuring in close proximity to the carina.17
Kiser et al11 reported an extensive review of the literature on
tracheobronchial ruptures sustained in blunt chest trauma between
1873 and 1996. In a total of 265 identified patients, they reported that
76% of the tracheobronchial disruptions occurred within 2 cm of the
carina11 (Fig. 3). The frequency of occurrence is most likely associated
with the orientation of the trachea and bronchi in relationship to other
structures increasing the susceptibility to disruption.

’ Mechanism

Understanding the mechanism and patterns of sustained injury is

paramount to thoroughly evaluate the presence of injury to the larynx
and trachea and to be able to assess the severity if injury is present. In
general, more energy is transferred over a broader area during blunt
trauma, and injury to the airway may occur despite no closely associated
104 ’ Nelson

Figure 3. Number of patients and injury location in 1-cm increments from the carina. From Ann
Thorac Surg. 2001;71:2059–2065.

injuries. Whereas, injury after penetrating trauma tends to be located in

close proximity to the wound.
Patterns of injury after blunt trauma are more commonly found to
be associated with multiple, widely distributed injuries, whereas
penetrating injuries are fairly limited to the path of the missile of
penetrating object (eg, knife). The risk for multiple injuries in blunt
trauma is related to the amount of energy transferred to the victim
during the injury and can be categorized as high-energy and low-energy
transfer. Injuries involving high-energy transfer include auto-pedestrian
accidents, motor vehicle crashes in which the vehicle’s change of speed
exceeds 20 mph or in which the patient has been ejected, motorcycle
crashes, and falls from heights greater than 20 feet. Low-energy trauma
frequently does not display widely distributed injuries and commonly
results from blunt assault, bicycle crashes, and low-height falls. Despite
the lack of multiple injuries, the injuries may still be extremely lethal
especially when laryngeotracheal injury is present (eg, a direct blow to
the neck with a blunt object).20,21
Penetrating injuries are classified according to the wounding agent,
that is, stab wounds, gunshot wounds, or shotgun wounds. Gunshot
wounds are further subdivided into high-velocity and low-velocity
injuries based on the speed of the bullet as kinetic energy is more
directly related to the speed of the bullet rather than its weight. This
is demonstrated by the formula relating mass and velocity to kinetic
energy:
Kinetic energy ¼ ðmass  velocity2 Þ=2
 Anesthetic Management of Airway Trauma ’ 105

Shotgun injuries are further subdivided into close-range (7 m) and

long-range wounds. Close-range shotgun wounds are comparable with
high-velocity wounds because the entire energy of the load is delivered to
a small area, often with devastating results. Long-range shotgun wounds
result in a diffuse pellet pattern in which many pellets miss the victim, and
those that do strike are dispersed and comparatively of low energy.22,23
Other determinants of injury include the presence of yaw at impact and
the amount of cavitation caused by the bullet as it penetrates the tissue.24
The amount of yaw may cause significant tumbling of the bullet through
tissue causing a wider path of injury and misdirection of the bullet (Fig. 4).
Despite a bullet entering tangentially in the posterior cervical area, it
may bounce of the cervical vertebrae tumbling the bullet anteriorly
to injury the larynx or trachea. On the other hand, cavitation relates to
the perpendicular waves sent out by the entering projectile, similar to the
waves seen on the surface of the water after an object penetrates it. The
damage caused by cavitation is greater for high-energy projectiles and
in organs that are solid and enhanced when combined with a tumbling
missile (Figs. 5, 6). Despite the larynx and trachea being hollow organs,
cavitation may cause airway compression as injury to adjacent tissues
results in edema and hematoma formation.24 Knowledge of the basics of
missile ballistics will aid the clinician in raising suspicion of possible airway
injury in patients with penetrating thoracic and neck trauma.

’ Blunt Trauma

Traumatic blunt injuries of the larynx and trachea most commonly

result from direct trauma or from sudden hyperextension.8 Commonly,

Figure 4. Yaw—notice that yaw decreases as distance from the barrel increases. From Injury. 2005;
36:373–379.
106 ’ Nelson

Figure 5. Empty can shot with pellet rifle (muzzle velocity B 1000 ft/s). From Injury. 2005;36:
373–379.

hyperextension usually results from acute deceleration in an unrest-

rained front seat driver; as the victim is thrown forward the larynx is
compressed between the steering wheel or dashboard and the rigid
cervical spine (Fig. 7). Coined ‘‘the padded dashboard syndrome’’
median or paramedian vertical fracture of the thyroid and/or cricoid
cartilage may result.25 As the pediatric airway is more flexible and has
increased mobility, they are much less susceptible to this form of injury
in comparison with the adult population.26–28 Although less commonly
reported, significant soft tissue and cartilaginous injury may occur
despite a lack of external evidence of laryngeotracheal injury.
More frequently, signs of laryngeal injury include stridor (may present
after exacerbated airway obstruction), subcutaneous emphysema,
hemoptysis, hematoma, ecchymosis, laryngeal tenderness, and flattened
thyroid contour.2 Other findings may include neck pain aggravated by
coughing or swallowing and dysphonia or aphonia dependent on the
degree of vocal cord or laryngeal nerve injury. It should be noted that
crepitus over the laryngeal shield is pathognomonic for laryngeal
fracture.29
Hyperextension itself can result in a traction and distraction injury
causing laryngeotracheal separation. Patency of the airway may be
maintained under spontaneous, negative pressure ventilation but
complete obstruction may occur with endotracheal intubation. This
commonly occurs as the endotracheal tube completely separates the
 Anesthetic Management of Airway Trauma ’ 107

Figure 6. Can filled with water showing effect of pressure wave generated by pellet (muzzle
velocity B 1000 ft/s). From Injury. 2005;36:373–379.

endolaryngeal structure previously held together by the peritracheal

connective tissue and surrounding musculature.8,30 Although similar
crushing trauma may occur in clothesline injuries, the force is
concentrated across a narrow band and is commonly accompanied by
a laceration.
Although the mechanism of intrathoracic tracheobronchial disrup-
tion from blunt trauma is not clearly defined, the trachea and bronchi
may be particularly susceptible to injury in these situations. Proposed
mechanisms include (1) a sudden forceful antero-posterior compression
of the thoracic cage producing a decrease in the antero-posterior
diameter with subsequent widening of the transverse diameter; the 2
lungs are then pulled apart causing disruption, (2) acute rise in intra-
airway pressure against a closed glottis during sudden chest compres-
sion causing airway rupture, and (3) rapid deceleration producing
sheering forces at points of airway fixation such as the cricoid cartilage
or the carina.17,31

’ Penetrating Trauma

Most injuries to the larynx and tracheobronchial tree are more

commonly due to stab wounds and gunshot wounds and are less
frequently the result of impalement or slash injuries.32,33 Wounds to the
anterior neck that penetrate the platysma have been historically divided
into 3 anatomically distinct zones3 (Fig. 8). As the anatomic zones relate
to the different structures within each zone, surgical management is
108 ’ Nelson

Figure 7. Most common mechanism of larynx and tracheal injury. From Cervicothoracic Trauma.
New York: Thieme Inc; 1986:121.

commonly based on the wound location within these zones. Therefore, a

thorough comprehension of the borders of each zone can assist
determining the risk of the penetrating injury involving the larynx
and/or trachea.
Zone 1 begins at the base of the neck extending from the sternal
notch to the lower border of the cricoid cartilage (equal to the upper
limits of the clavicle), and is also referred to as the thoracic outlet.3
Fortunately, injuries to zone 1 occur less frequently but are associated
with a very high mortality as there is a high risk of injury to the great
vessels in this zone.33–35 In stable patients with zone 1 injuries that direct
toward the aortic arch, angiography may be justifiable; however, dog-
matic mandatory use of vascular imaging has recently decreased.36,37
Zone 2 is the central portion of the neck extending from the top of
zone 1 to the angle of the mandible.3 Zone 2 injuries are the most
common, but fortunately, carry a lower mortality than either zone 1 or
zone 3 injuries.33–35 Although some studies have reported a frequency
as low as 50%, most studies report between 70% and 80%.33,38,39
Although easy exposure of this zone contributes to its increased
frequency of injury, its easy exposure allows injury assessment to be
more straightforward as well. Unstable patients or those with evidence
of airway compromise, expanding hematoma, or significant external
hemorrhage are usually explored in the operating room promptly. In
contrast, conservative management consisting of careful observation is
 Anesthetic Management of Airway Trauma ’ 109

Figure 8. Location of the 3 zones of the back. From Cervicothoracic Trauma. New York: Thieme Inc;
1986:95.

commonly the treatment of choice in the stable patient with neck

wounds that penetrate the platysma.33,34
Zone 3 injuries extend from the angle of the mandible to the base of
the skull.3 Problems with exposure in this region can make surgical
management particularly difficult especially with injury to the distal
carotid artery, however, laryngeotracheal injuries are fairly uncommon
when the wound is above the angle of the mandible.

’ Diagnosis

Accurate diagnosis of tracheobronchial injury first and foremost

necessitates a high index of suspicion based on the mechanism, pattern,
and location of injury. Nevertheless, detection of airway injury, and
therefore management, remains controversial. In patients with sig-
nificant trauma to the larynx or trachea causing airway compromise or
110 ’ Nelson

obvious clinical signs, physical examination is highly effective for

assisting accurate diagnosis. Unfortunately, this is seen in relatively few
patients.34,37,40,41 Some patients have their diagnosis confirmed during
direct laryngoscopy as these patients frequently require endotracheal
intubation and mechanical ventilatory support. In patients with certain
‘‘soft’’ signs after penetrating neck injury, physical examination is
markedly less accurate in detecting injury.42–44
Dyspnea, respiratory distress, subcutaneous emphysema, laryngeal
tenderness, and hemoptysis are the most common signs and symptoms
found in patients with airway injury.11,12,45 Additional clinical signs
include flattened thyroid contour while crepitus over the larynx is
pathognomonic for laryngeal injury.2
Cervical and chest roentgenogram may be useful for initial detection
of laryngeotracheal injuries and for raising the index of suspicion for
airway injury. Cervical mediastinal emphysema, disruption of the airway
contours, and displacement of the endotracheal tube may be present
and should suggest the possibility of an injury to the airway. Mordehai
et al46 reported that pneumomediastinum and cervical emphysema are
the most sensitive chest roentgenographic markers of airway rupture.
However, persistent pneumothorax despite properly placed thoracost-
omy tubes may be the only radiographic evidence of injury12 (Fig. 9).
Altlhough a neck computed tomography may facilitate the detection of
laryngeal injury, it may be less valuable in detecting tracheal injury
especially in the intubated patient.
Many times intraoperative endoscopic evaluation is required for
accurate diagnosis. Laryngoscopy is very accurate in detecting injuries
involving the larynx while bronchoscopy is less accurate in detecting
injuries in the upper cervical airway because the presence of an
endotracheal tube can obscure visualization of the injury.47 Atlhough
bronchoscopy is limited in higher airway injuries, it still remains the
most reliable method to detect lower tracheobronchial injury.44,45
Although rigid bronchoscopy requires general anesthesia it usually
allows improved visualization especially when significant blood and
debris exist in the airway. Flexible bronchoscopy can be performed with
topicalization and mild sedation and may provide improved visualiza-
tion in to the lower bronchi. Regardless, combining all 3 of these
modalities allowed 100% detection of airway injury after penetrating
neck trauma.44,47

’ Associated Injuries

The neck houses several vital structures in close proximity

increasing the frequency of associated injuries in both blunt and
penetrating airway injury. The majority of associated injuries after
 Anesthetic Management of Airway Trauma ’ 111

Figure 9. A, Chest x-ray from the referring facility shows endotracheal intubation, bilateral chest
tubes with small residual right pneumothorax. B, Chest x-ray after transporation from referring
facility. Note the progression of the right pneumothorax and presence of pneumomediastinum, despite
functioning chest tubes. The endotracheal tube has been pulled back, out of the right mainstem
bronchus, which contributed to the expansion of the pneumothorax. From J Pediatr Surg. 1998;33:
1707–1711.

tracheobronchial trauma include injuries to the vascular structures and

the digestive tract. Although usually clinically ‘‘silent,’’ digestive tract
injuries may produce similar signs and symptoms as laryngeotracheal
112 ’ Nelson

injuries. They are frequently diagnosed intraoperatively during endo-

scopic interrogation. Similar to injuries affecting the airway, missed
injuries and subsequent delayed diagnosis are associated with a high
mortality.48
Injuries to the major vascular structures is easy to detect especially
when clinically ‘‘hard’’ signs are present, such as pulsatile bleeding,
expanding hematoma, and unilateral neurologic deficit are present.
However, associated vascular injury may occur with minimal external
signs but may be as devastating especially in blunt trauma with
associated intimal injury.49,50
Maxillofacial injuries are frequently involved in airway disruption
after blunt trauma.2 This may lead to significant difficulty when
attempting to place an artificial airway and may suggest cervical spine
injury especially when associated with high-velocity facial fractures.51
Careful attention to cervical spine stabilization should be maintained, as
in all trauma patients, when securing the airway in a patient with
maxillofacial trauma.
Cervical spine injuries occur more in blunt trauma patients than in
those victims of penetrating trauma.52,53 Penetrating trauma to the
cervical spine represents 14% of all spinal injuries.54 Although less
obvious in blunt trauma, the presence of devastating neurologic injury
in penetrating neck trauma should facilitate the diagnosis of cervical
spine injury. If the diagnosis still remains unclear, cervical roentgen-
ogram and computed tomography scan of the neck should confirm the
diagnosis unless the damage is an isolated ligamentous injury in which
case dynamic plain films or magnetic resonance imaging may be
required. Nonetheless, when airway injury is present, spinal precautions
should always be maintained especially when attempting to secure the
airway or during endoscopic evaluation of the aerodigestive tract.

’ Airway Management

Ensuring a patent airway is the initial step in managing any trauma

patient. Similarly, ensuring a patent airway is the first goal when trauma
to the larynx or trachea occurs, however, this may be more difficult in
these patients. The specific technique and route of intubation is
multifactorial and dependent on the patient’s anatomy, extent and type
of injury, associated injuries, urgency, location of the patient, skills of the
airway professional, equipment available, and presence of surgical
colleagues. Nevertheless, attempts to maximally preoxygenate the
patient, maneuvers to improve oxygenation, and ventilation (‘‘jaw-
thrust,’’ patient positioning, etc) should be performed. In addition,
surgical airway equipment, and a surgical colleague (trauma, otolaryn-
gology, oral-maxillofacial) should always be present whenever
 Anesthetic Management of Airway Trauma ’ 113

attempting to secure the airway in these patients. This may mean that
the best means for securing the airway may have to be performed in the
operating room with the patients neck surgically prepped.
It is preferred to maintain spontaneous ventilation while securing
the airway. Although commonly used in trauma situations, the use of
rapid-sequence in these cases is usually not recommended as the loss of
motor tone may completely obstruct the airway or complete an existing
tracheal separation being held together by the surrounding muscula-
ture.55
Often times, in the presence of significant laryngeotracheal injury,
tracheostomy is required and frequently performed with the patient
awake using local anesthetic.2 Although not contraindicated, obvious
care must be taken when attempting endotracheal intubation in these
patients. Despite an atraumatic laryngeal inlet, severe consequences
such as complete tracheal obstruction may still occur. This happens
when a false passage is created by an advancing endotracheal tube as it
passes through a disrupted or lacerated part of the trachea. In addition,
the high frequency of associated cervical spine injuries mandates the
maintenance of in-line traction during all airway procedures. The
flexible bronchoscope may be a vital piece of equipment used during
intubation with these patients. If adequately topicalized, these patients
can be spontaneously breathing while the airway is being secured.
Remifentanil may provide adequate analgesia alone while maintaining
spontaneous ventilation in those patients who are hemodynamically
stable but are unable to achieve adequate topicalization.56 In addition,
the flexible bronchoscope can direct the endotracheal tube into a
mainstem bronchus past the area of injury if needed. Unfortunately, the
use of a flexible bronchoscope may be limited in emergent situations and
in airways with extensive bleeding or debris. Although not reported, it
does seem logical that a flexible bronchoscope may assist safe placement
of the endotracheal tube in these situations by the following method:
(1) an endotracheal tube is placed into the entrance of the larynx by
direct laryngoscopy, (2) the flexible bronchoscope is advanced through
the endotracheal tube bypassing the blood and debris in the hypo-
pharynx, (3) the bronchoscope is continued to be passed into the trachea
examining for tracheal disruption, and (4) the endotracheal tube is then
‘‘railroaded’’ over the bronchoscope to the desired position. Confirma-
tion of correct position can be made as the bronchoscope is withdrawn.
Anesthetic agents should be administered only after the endotracheal
tube is confirmed to be in the correct position. In the event that a
flexible bronchscope is not able to pass, the point of injury the patient
may have to be maintained spontaneously breathing via mask ventilation
or supraglottic device. In these situations, risks of aspiration should be
minimized and continued vigilence maintained for evidence of gastric
contents entering the airway.
114 ’ Nelson

Management of injuries to the distal airway is obviously extremely

challenging. Placement of the endotracheal tube past the site of injury
may require endobronchial intubation. Because of the large size and
rigidity of a double lumen tube, attempts at lung isolation using an
endobronchial blocker or endobronchial placement of the endotracheal
tube should be attempted. Rarely, airway access through a median
sternotomy or thoracotomy is required.

’ Surgical Management

The management of these injuries is complex and sometimes

controversial and the anesthetic management is critical in these
procedures. The choice and timing of anesthetic agents, route and
mode of intraoperative ventilation require continuous communication
between the anesthesiologist and the surgeon to have a successful
surgical strategy. Frequently, surgical access limits ventilation access and
intermittent interruption of both occurs throughout the procedure
especially when the injury is to the lower airway.
Many different algorithms exist in guiding the management of these
injuries and the decision to proceed down the appropriate care plan is
multifactorial2,34,44,57 (Fig. 10). Management of those patients who are
either hemodynamically unstable or have ‘‘hard’’ signs of injury usually
are straightforward and include surgical intervention. Controversy
exists in the group of individuals who are hemodynamically stable and
have ‘‘soft’’ signs of aerodigestive or vascular injury. Conservative
management using a combination of clinical, radiographic, and
endoscopic surveillance is incorporated into the management of these
patients. In a group of penetrating neck trauma patients without ‘‘hard’’
signs of injury, Meinke et al58 showed that by selectively exploring
these patients they were able to decrease the negative exploration
rate by greater than 50% while maintaining the same overall
mortality as those undergoing mandatory exploration. Furthermore,
the negative exploration rate was reported to be as low as 5% when
violation of the platysma was excluded as criteria for mandatory
exploration.59
Surgical management of injuries to the trachea have been well
described by Grillo and a thorough discussion extends beyond the scope
of this review.60 Briefly, tracheal wounds can be repaired primarily
especially in wounds that are small with minimal devitalized tissue.
Absorbable suture is commonly used as permanent suture but it is
associated with an increased risk of granuloma formation.36 Large
defects or injuries that require significant debridement before repair
may require release procedures, musculofacial flaps, or rarely, synthetic
material. Flexion of the neck, by placement of chin-sternal skin retaining
 Anesthetic Management of Airway Trauma ’ 115

Figure 10. Assessment and treatment protocol of penetrating neck injuries for low volume centers.
From Injury. 2006;37:440–447.

sutures, may be performed to relieve tension on the repair. The use of

tracheostomy is unclear and its use is based on the location of the repair
and the presence of associated injuries.60,61
Surgical experience repairing injuries to the larynx is somewhat
limited because of the rarity of the injury. However, it is recommended
that tracheostomy under local anesthetic is performed for all suspected
laryngeal trauma patients because of the increased risk of iatrogenic
injury when attempting endotracheal intubation.2,62 The goal of
treatment in repairing the larynx is to restore its function as it relates
to phonation, ventilation, and deglutination. Reapproximation of larger
defects may be more difficult than in the trachea and may require stent
placement. Overall, those patients who undergo repair in the first 2 days
and those who can be managed conservatively have improved outcomes
with less complications.2
116 ’ Nelson

’ Conclusions

Fortunately laryngeotracheal injury is rare but should always be

considered to be life-threatening. Maintaining a high index of suspicion
based on the mechanism of injury and clinical signs and symptoms may
facilitate a rapid diagnosis. Maintaining a patent airway is the primary
goal in these patients and may require a team approach especially
in patients with significant airway injuries. Frequently, these are not
isolated injuries and the knowledge of anatomy and the mechanism of
injury will help establish a treatment strategy to best care for the patient.
The best outcomes for patients with laryngeotracheal injury are those
that can be managed conservatively or those that are treated promptly.

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